On June 2, the Portland Public Schools Board announced an investigation into the lead water testing program in the district. PPS hired the law firm Stoll Berne to conduct the investigation and to issue a report within 30 days.

The analysis reviewed the systems and procedures for water testing, evaluated the management of information and identified operational or personnel breakdowns. Here are some of the most important takeaways from that report:

The report identified inconsistent policies and practices within every part of the lead testing program, from inconsistent testing itself to flawed internal information management to misleading communication with parents, teachers and media.

Measures to restrict access to drinking water after high lead test levels were ineffective or inconsistent -- knowingly exposing people to leaded water while waiting to make repairs.

The lead testing activities were primarily reactive and performed in response to inquiries from parents or staff, instead of preventative -- and did not follow EPA guidelines for retesting.

The entire responsibility for the district lead testing program fell to one individual within the system, the PPS Senior Manager of Environmental Health & Safety. Until 2014, that was Patrick Wolfe, who then retired and was replaced by Andy Fridley, who was given no training for lead testing.

There were serious internal communication gaps between the lead testing program and PPS executives. Stoll Berne cited a lack of institutional knowledge on the part of executives and an absence of diligent inquiry by these high-level administrators.

The only record that kept track of lead testing and remediation was a database that was inconsistently updated and never audited or verified.

Stoll Berne described PPS communication as inaccurate and misleading. PPS website information was presented in a way that implied that after the 2001- 2002 testing that all drinking fountains were safe when they were not. The text also implied that retesting was unnecessary when that is an EPA best practice.

In one case, the investigation cited PPS communication as inaccurate when the former Chief of Communications & Public Affairs Jon Isaacs knowingly provided incomplete excerpts of the water testing database to the Willamette Week.

PPS set a policy that people should drink only from water fountains and not sink faucets. This was not well communicated. The information was found online, in an email newsletter and in a handbook, but the Wolfe and Chief Operating Officer Tony Magliano decided against district-wide labeling of sinks.

The board and executive leadership cited budget concerns and said they had prioritizing education over infrastructure or repair issues. When they did address repair issues, PPS focused on the health and safety issues that are regulated by law. Lead testing and remediation is voluntary so it went mostly unaddressed.